Life Safety Compliance: Understanding the Basics

By William Phillips,
Owner, RITEway Building Services

One of the biggest challenges facing ASC administrators is
the need to become an expert at practically everything concerning their surgery
center as there is typically an expectation from their governing boards that
the buck stops with them. While administrators may not need comprehensive
knowledge of all aspects of surgery center management, they must understand the
fundamentals of many subject areas in which they may not have a working
background or experience. One such area is life safety.

“Life safety” is a phrase that administrators will
come to know very well as time goes on in their career. Every licensure and
accreditation survey has a component devoted to life safety. On the surface, maintaining
compliance with life safety can seem like a lot of ongoing responsibility,
which is made even more complicated by rule changes that occur approximately
every three years.

There are many compliance items that you are able to control
as part of life safety compliance and many items that you cannot control. It is
difficult to control how your physical plant was designed and built. That is
the fundamental foundation of how life safety compliance criteria are applicable
to your facility. What you can do is ensure the operational compliance
inspections and checks required for your existing physical plant are performed as
closely as possible to the standards prescribed in the regulations being
enforced by surveyors visiting your site. Do so regularly and your survey outcomes
are more likely to be positive.

Here are some areas of focus to help improve life safety
survey compliance.

Physical Plant Tour

The tour is the most important part of the physical plant
life safety compliance survey. Obvious “housekeeping”—and by that I mean maintenance-related
issues—must be taken
care of and addressed prior to the survey. Evidence of compliance on the tour should
stand out as evidence that you have a solid physical plant maintenance program
in place. This will likely impress surveyors, even if you have the oldest
surgery center ever built. A positive first impression speaks a lot toward your
management of compliance.

Safety Officer Responsibilities

The key person relative to your general safety and life
safety compliance is your safety officer. Make sure this individual is
supported and encouraged. Your safety officer should make regular rounds and document
everything found to be out of compliance. Simply because you document
everything doesn’t mean that you have to correct or make improvements on
everything that safety officer may identify as noncompliant. Rather, if a
deficiency is found that may not be feasible to correct based upon your surgery
center’s operations or financial constraints, it is worth documenting and
recording as an action item or, in some cases, creating a life safety
deficiency report on this very item. Review and document these items at your quality
assurance and performance improvement meetings and send the documentation to
your governing board members for their review.

Prior to any life safety survey, present this record of your
perceived life safety deficiencies to the surveyor(s) to demonstrate that you
are aware of issues that may be corrected by future actions. This shows the
surveyor that you are on top of your life safety management compliance program.

Documentation

Regardless of whether documentation is electronic or written,
it must trace compliance actions from inspection of a particular device to a
pass or fail determination—and
if failed, a corrective action. The corrective action may be in the form of written
compliance action, usually a work order. This traceable work action can refer
to a single or group of devices checked, whether they be electrical
receptacles, biomedical equipment or individual components on the fire alarm
system. The same rules apply everywhere.

Final Thoughts

While life safety operational compliance is something that
you must constantly be aware of, try not to let it become overwhelming to the
point where you worry about it incessantly. All required inspections and checks
must occur regularly, so implement a reminder system. Ensure documentation is
complete and records are maintained in a common area for easy review and
reference. This is vital to passing a survey.

And remember: The first impression of your physical plant will
often drive the rest of the inspection. Good luck!

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